{"paper_id":"38c00f8a-cb5d-4604-a9d9-b0a1e0a47b73","body_text":"Title: Dyspareunia in their own words: A comprehensive qualitative description of endometriosis-\nassociated sexual pain \n \nCorresponding Author: Dr. Paul Yong \nAssistant Professor, Department of Obstetrics & Gynecology, University \nof British Columbia \nBC Women’s Center for Pelvic Pain and Endometriosis \nF2-4500 Oak Street, Vancouver, British Columbia, Canada, V6H 3N1 \nTel: +1-604-875-2534; Email: paul.yong@vch.ca \n \nCo-authors: Kate J Wahlab, Shermeen Imtiazb, KS Josephab, Kelly B Smithb, Paul J. Yongb, Susan \nM. Coxa  \na School of Population and Public Health, University of British Columbia, Vancouver, Canada \nb Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada \n \n \n \n  \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n1 \n \nBackground: Dyspareunia is a classic symptom of endometriosis but is neglected in research \nand clinical contexts. This study explored the experience of this endometriosis-associated sexual \npain. \nMethods: This was a qualitative descriptive study that included people who had experienced \nendometriosis-associated dyspareunia alone or with a partner. Data collection involved semi-\nstructured interviews with a female researcher that began with an open-ended question about \ndyspareunia and included interview prompts related to the nature of sexual pain. Interviews were \nrecorded, transcribed verbatim, and analysed for themes.  \nResults: 17 participants completed interviews. The mean participant age was 33.3 (SD=7.2) and \nmost participants identified as white (82%), were college-educated (71%), identified as \nheterosexual (65%), and were partnered (59%). Location, onset, and character emerged as \nimportant, interrelated features of endometriosis-associated dyspareunia, as did severity and \nimpact. Dyspareunia occurred at the vaginal opening (n=7) and in the abdomen/pelvis (n=13). \nPain at the vaginal opening began with initial penetration and had pulling, burning and stinging \nqualities. Pain in the pelvis was typically experienced with deep penetration or in certain position \nand was described as sharp, stabbing and/or cramping. Dyspareunia ranged from mild to severe, \nand for some participants had a marked psychosocial impact.  \nConclusions: Dyspareunia is a heterogeneous symptom of endometriosis that ranges in severity \nand impact. Disaggregating dyspareunia into superficial and deep types may better reflect the \netiologies of this pain, thereby improving outcome measurement in intervention studies and \nclinical care.   \n \n  \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n2 \n \nINTRODUCTION \nEndometriosis is a gynecological condition that affects 10 percent of females and is \ncharacterized by the growth of ectopic endometrial-type tissue. [1] More than half of people with \nendometriosis experience pain during sexual intercourse.[2,3] This pain, called dyspareunia, is \nassociated with psychosocial sequalae including poor quality of life,[3,4] low self-esteem,[5–7] \nand relationship difficulties.[5,7,8] \nDespite its prevalence and impact, dyspareunia is considered a ‘neglected symptom’ of \nendometriosis.[9] Clinically, its neglect has been attributed to embarrassment and normalization \nby clinicians and patients as well as a dearth of evidenced-based treatment options.[8,9] \nDyspareunia has also been neglected in the research context, where it is not validly \noperationalized and studies are underpowered to detect relevant outcomes.[10] \nSeveral qualitative studies have highlighted the impact of dyspareunia on the lives of people with \nendometriosis.[5–8,11,12] Qualitative data about dyspareunia have also been collected for the \ndevelopment of patient-reported outcome measures of endometriosis pain.[13–18] However, \nreporting of the results has not focused on sexual pain and demographic characterization of \nparticipants is often limited.  \nLargely absent from the literature is a complete description of what endometriosis-associated \nsexual pain feels like or where and when it happens. The aim of this study was therefore to \nprovide a comprehensive account of dyspareunia in the everyday terms people with \nendometriosis use to describe the pain. Such data are required to support more accurate \nphenotyping of this symptom in clinical and research contexts.    \nMATERIALS AND METHODS \nDesign \nThis was a qualitative descriptive study. Compared to other approaches, qualitative description \nrequires less interpretation and instead focuses on identifying and reporting the fundamental \nelements of an experience in the words of participants.[19] \n \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n3 \n \nPatient and Public Involvement \nThe research conducted by our team is guided by a Patient Research Advisory Board. The Board \napproved the study design and was not involved with recruitment. Participants will receive the \npeer-reviewed article with a plain language summary of the results.  \nParticipants and Recruitment \nParticipants were recruited from the Endometriosis Pelvic Pain Interdisciplinary Cohort data \nregistry (ClinicalTrials.gov Identifier: NCT02911090). The data registry is open to patients \nattending a tertiary centre for endometriosis and captures longitudinal demographic and clinical \ndata. Potential participants were enrolled in the data registry and consented to be contacted for \nresearch. Inclusion criteria were age of 18 years or older, clinically suspected or diagnosed \nendometriosis, and current or previous dyspareunia alone or with a partner. Exclusion criteria \nwere never sexually active alone or with a partner, no history of dyspareunia alone or with a \npartner, and inability to communicate in English. Recruitment continued until saturation, the \npoint when additional interviews did not reveal new insights about the experience of sexual pain. \nTo reflect the demographic characteristics of patients seen at the tertiary centre, potential \nparticipants were randomly selected from within overlapping education, sexual orientation, and \nethnicity groups. KW contacted selected participants by phone to present the study, introduce \nherself and her program of research, and screen for eligibility. Interested participants received \nand returned consent forms by e-mail. To reduce bias, each selected participant was called a \nminimum of five times and at different times of day before a subsequent participant was selected.  \nData Collection and Analysis \nThe interview guide was developed by KW, a graduate student with theoretical and applied \ntraining in qualitative methodologies, SC a qualitative health researcher focused on illness \nexperiences throughout the life course, PY a clinician-scientist with expertise in endometriosis, \nand members of the Patient Research Advisory Board for the Centre for Pelvic Pain and \nEndometriosis. KW pilot tested the interview guide and conducted a single one-on-one semi-\nstructured telephone interview with each participant. Each interview began with the question \n“Tell me about the pain you experience with sex”; initial prompts related to a priori themes of \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n4 \n \npain site, onset, character, radiation, associations, time course, and exacerbating/relieving \nfactors. Contemporaneous field notes permitted the identification of emergent themes and \nassessment of saturation. Demographic and clinical data were drawn from the data registry.   \nThe interviews were audio recorded and transcribed verbatim by KW, SI, and a research \nassistant. Using Nvivo 12 Pro,[20] KW conducted a qualitative content analysis of the \ntranscripts.[21] The analysis involved reading the set of transcripts to get a global sense of the \ndata; reading transcripts individually and highlighting words that captured key concepts as codes; \nsorting the codes into categories based on relatedness; and organizing the categories into \nmeaningful clusters.  \nTo ensure reliability of the analysis, SI coded two randomly selected transcripts and cross-\nchecked her findings with those of KW. Transcript and analysis checking with the participants \nwas not completed given the low-inference approach to analysis.    \nRESULTS \nParticipants \nOf 50 potential participants we attempted to contact about the study, 17 completed an interview, \n11 could not be reached, 10 were ineligible, 4 declined to participate, and 8 were lost to follow \nup. The average age of the participants was 33.3 years (SD=7.2, range 23-50). Race, gender \nidentity, sexual orientation, educational attainment, marital status, parity, and endometriosis \nstatus are described in Table 1. Mean dyspareunia scores for initial penetration and deep \npenetration on an 11-point numeric rating scale (0=no pain, 10=worst pain imaginable) were 3.3 \n(SD=3.4, range 0-8) and 6.6 (SD=2.8, range 0-10) respectively. The average interview length \nwas 28 minutes (SD=13, range 14-72). \n \n \n \n \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n5 \n \nTable 1 Demographic characteristics of the study sample \nCharacteristic mean ± SD, \nrange; n (%) \nAge 33.5 ± 7.0, 23-50 \nRace  \nWhite 14 (82) \nAsian 2 (12) \nOther 1 (6) \nFemale Gender Identity 17 (100) \nSexual Orientation  \nHeterosexual 12 (70) \nBisexual 2 (12) \nLesbian 2 (12) \nOther 1 (6) \nEducation  \nHigh school (grades 9-12) 1 (6) \nCommunity college/vocational school 3 (18) \nCollege 9 (52) \nGraduate school 4 (24) \nMarital Status  \nSingle 2 (12) \nDating 2 (12) \nCommon law 2 (12) \nMarried 9 (52) \nSeparated 2 (12) \nParous 4 (24) \nEndometriosis status  \nClinically suspected 10 (59) \nSurgical (visual) diagnosis 1 (6) \nSurgical (histological) diagnosis 7 (41) \nCurrent endometrioma on ultrasound 2 (12) \nCurrent nodule on examination 2 (12) \nDeep dyspareunia score 6.76 ± 2.82, 0-10 \nSuperficial dyspareunia score 3.24 ± 3.33, 0-8 \n \nAlthough five participants did not self-identify as heterosexual in the data registry, only one \nexplicitly mentioned her sexual orientation in the interview. These participants did not report \nexperiences of sexual pain different from those of other participants.  \n \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n6 \n \nPain Fundamentals \nTable 2 shows that across participants, pain began at different points in the sexual encounter. The \ntable also shows that participants used a range of terms to describe the character and anatomic \nlocation of their endometriosis-associated sexual pain.  \nTable 2 Terms used to describe sexual pain \n  Term† n†† Example [participant ID] \nOnset at the beginning 7 Right when he like starts to go in [033]  \ndeep penetration 7 It starts as soon as I have deep penetration [109]  \ncertain positions 6 All of a sudden there was an angle that went slightly one or the \nother, it might be like “Ahh! That hurt!” [097]  \norgasm 2 My experiences of it have been that it’s associated with orgasm \n[020]  \nafterwards 2 For the most part, its cramps afterwards [050] \nSite pelvis 7 Very deep in the pelvis [50]  \nvaginal opening 7 It’s mostly around the vaginal opening [068]  \nabdomen 5 Up in my abdomen [030]  \nuterus 5 Right in my uterus area [33]  \ncervix 4 Inside my cervix [031]  \ndeep vagina 4 The very back end of the vagina and the bottom [097]  \novaries 4 Around where my ovaries are [038]  \nrectum 2 The rectum area [087]  \nstomach 2 I feel it right in my stomach [51]  \nCharacter sharp 7 I’m having such sharp pain [035]  \nache 6 It felt like an ache, that’s what it sort felt like, like a real ache \n[015]  \ncramping 5 A really, really bad cramp [089]  \nstabbing 5 A stabbing pain, I guess you could call it [045]  \nspasm 3 I almost feel like, it’s like a spasm that happens [051]  \nbruise 2 It feels almost like a bone bruise [109]  \nburning 2 It felt like it was burning [031]  \ninflamed 2 Everything is inflamed [051]  \npulling 2 It feels like my whole insides are being pulled around [038]  \npulsing/throbbing 2 It's kind of like pulsing [033]  \npunching 2 It’s like something is punching you [130]  \nstinging 2 It's kind of like a stinging feeling [033]  \ntense/tight 2 That part of me is still very tense and tight [068]  \nuncomfortable 2 It’s an uncomfortable feeling [087] \n† All terms used by two or more participants are included \n†† Number of participants who used the term or stemmed word (e.g., talk, talking); sum is greater than the total number of  \nparticipants because participants typically used several terms to identify the site of sexual pain.   \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n7 \n \nSome participants had difficulty naming the site of their pain and occasionally explained its \nlocation in terms of other painful experiences. \nI’m not really not familiar with my biology, the reproductive parts. But the inside. So is it \nthe cervix? Or the uterus? [130] \nThat’s really hard to explain, because I can’t really pinpoint where it is. It’s not on the \noutside, it’s the inside where, if I was pointing at my pelvis, like a couple inches in. [089] \nThe same place I would experience period cramps. [051] \nAll participants experienced pain in the pelvis or pelvic organs and seven participants also \nexperienced pain at the vaginal introitus. For example, participant 020 said, \nI have a few different things with pain with penetration.  \nThis participant went on to clarify, \nSo I experience the three types of penetrative pain so like the penetrative pain in my \nvagina, and then deep vaginal pain, and I also experience uterine pain with arousal and \norgasm.  \nExcept for two participants who reported pelvic pain at orgasm and two who reported pelvic pain \nafter intercourse, pain in this area began with deep penetration or certain sexual positions and \nwas associated with sharp, aching, cramping or stabbing feelings. In contrast, pain at the vaginal \nopening always began with initial penetration and was associated with pulling, stinging, or \nburning.  \nPain Severity \nWhen asked about the severity of their pain, 14 participants spontaneously rated their pain as a \nscore out of 10. Participants also described the severity of their pain.  \nIt’s not so bad where you’re like heeled over, like when you have your period with endo, \nwhere you can’t move or anything like that, it’s not even close to that, it’s just, it’s more \nuncomfortable I’d say. [030] \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n8 \n \nI could keep going if I mentally prepared myself but there is also like a side to me that \nwould just want to stop. [033] \nSo, it wasn’t the worst pain I’d experienced but it was uncomfortable enough that I would \nhave to stop doing that activity. [043] \nIt wasn’t quite at a level I would pass out from the pain, but I would definitely cry quite a \nbit. [031] \nThe worst pain I’ve ever felt. Nothing could be done, I can’t have people around me, I \ndon’t like noises, I just want everyone to just leave me alone. There’s nothing that can be \ndone for it to really go away you know, until it goes away. I don’t know, it’s scary. [051] \nPain Impact \nFifteen participants reported having interrupted sex because of pain and ten had avoided sexual \nexperiences.  \nThe experience of sexual pain affected the emotional and psychological well-being of some \nparticipants. \n It’s hard for me to just deny all the time because I start to feel bad. [033] \nIt would make me feel sort of you know, emotionally kind of discouraged. [043] \nI feel insignificant, you almost feel broken or something. [051] \nYou feel guilty for having to stop. [089] \nMany participants also reported that the experience of sexual pain impacted their intimate \nrelationships.  \nI think my husband was reluctant to approach me for sex because he knew I was feeling ill. \nYou know, you don’t want to ask somebody who’s feeling ill to “Hey let’s go!” I’m glad \nwe’ve got a solid marriage and we’ve weathered the storms and we’re ok now. But it was a \nreally tough time. [043] \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n9 \n \nI don’t ever want to have sex, I would be happy to not do it at all, but I have to get myself \nin the mood. I try once a month to have, you know, that closeness with him even though for \nme its not pleasurable at all […]. It has kept me keeping some secrets from my lover, which \nis not how our relationship normally is. [038] \nLately, we just have sex is because we want to conceive, or try to conceive [...] we don’t \nreally have sex just because we wanted to. [130] \nIt got to the point where I was in pain so often from intercourse, that my partner and I \nbasically decided that we just weren’t going to anymore, that it just wasn’t worth me going \nthrough the pain […] It contributed to the end of that relationship. [031] \nFor one participant who was single, sexual pain affected her willingness to seek out physical \nintimacy. \nI don’t want to watch the horrified faces as I’m suddenly leaping out of bed because I’m in \nso much pain. [035] \nSome participants had sexual intercourse infrequently or not at all. Four participants reported that \nhormonal treatment relieved their pain, but in one instance the treatment also negatively affected \nsexual desire. Other participants found ways of managing and coping with their pain.  \nI typically have to take anti-inflammatories for the pain and just managing it, or a hot \nwater bottle, a hot shower, that sort of thing. [109] \nWe went out and bought that masturbation sleeve and we kind of control the depth just to \nkind of prevent [the pain] from happening. [051] \nI just think about noises or him speaking to me and I really just focus on that. I take my \nmind away from what’s actually happening. [033] \nI have pain with penetration almost all the time, but I am able to accommodate it in a way \nso it’s not severe enough that it stops the experience and like I can change a position or \nstop having penetration and it’s fine and I can continue with my sexual experience. [020] \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n10 \n \nI’ve gone to therapy to try to stop myself from feeling guilty right away and just be okay \nwith the fact that like, we might have to change things up and that’s okay. [089] \nDISCUSSION \nThis study set out to identify the fundamental features of endometriosis-associated dyspareunia. \nParticipants reported pain in the pelvis or pelvic organs, which generally began with deep \npenetration or certain positions and had a sharp, aching, cramping, or stabbing quality. Almost \nhalf of participants also experienced pain at the vaginal opening that began with initial \npenetration and had a pulling, burning, or stinging nature. This pain ranged in severity and in \nsome cases had a significant, negative impact.  \nAlthough participants sometimes struggled to describe the location of their sexual pain, our study \nshowed that dyspareunia typically occurred in the pelvis and at the vaginal opening. These \nresults aligned with research by Fauconnier et al. that identified five themes associated with \nsexual pain: strong and sharp pain, deep internal pain, pain in certain positions, distracting pain \nthat prevents or disrupts intercourse, and a burning feeling during or after intercourse.[22] \nClinically, the finding of pelvic pain with deep penetration corresponds with the understanding \nof endometriosis-associated dyspareunia whereas the description of pain at the vaginal opening \nthat begins with initial penetration mirrors the presentation of other gynecological conditions like \nprovoked vestibulodynia.[23]  \nImportant secondary findings of this study related to the impact and management of \nendometriosis-associated sexual pain. Dyspareunia had a variety physical, emotional, mental, \nand interpersonal effects that participants managed with medical, physical, and cognitive \ninterventions. These results aligned with previous work recommending a biopsychosocial model \nand interdisciplinary treatment approach for endometriosis-associated sexual pain.[24,25]  \nThe defining strength of the study was its exclusive and in-depth approach to characterizing \nendometriosis-associated sexual pain. The findings confirmed and extended those of Fauconnier \net al., who described dyspareunia using data from 10-minute French-language interviews about \npainful symptoms of endometriosis.[22] Additional strengths were that the study sample was \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n11 \n \nselected to reflect the demographic characteristics of the clinical population and that participants \nranged in severity of their self-reported sexual pain.  \nAn obvious limitation of the study was that participants were not selected based on gold-standard \nsurgical diagnosis (Table 2). However, this reflects a shift towards clinical diagnosis in \npractice.[26] A second limitation was that all participants had previously attended a tertiary \ncentre where they completed dyspareunia measures and discussed the sexual pain with a care \nprovider. Together with high levels of education in the study sample, earlier clinical interactions \nmay have affected how participants described their pain. \nOur findings have implications for endometriosis-associated dyspareunia in clinical research. \nFirst, measuring sexual pain without distinguishing between pelvic pain and pain at the vaginal \nopening may capture dyspareunia that arises from other conditions,[27] thereby leading to \nmisclassification and potentially biasing the effect of interventions toward the null. Second, \nreliance on onset- or location-based vocabulary in patient-reported measures might limit \nresponse accuracy; diagrams that highlight the relevant anatomic sites could facilitate true \nresponses. Third, although recent clinical trials have used ordinal response options (i.e., none, \nmild, moderate, severe),[28] reporting dyspareunia on a scale of 10 is intuitive for respondents \nand aligns with recommendations for the measurement of patient-important endometriosis pain \nsymptoms.[29] Finally, research focused on sexual pain should seek to account for the physical \nand emotional impact of this symptom.    \nClinically, our findings suggested that people who experience endometriosis-associated \ndyspareunia have unmet treatment needs. Asking whether a patient has any concerns regarding \npain with sexual activity that they would like to discuss can avoid neglect of this symptom due to \ntaboos or normalization.[5,6] For patients who consider their sexual pain a priority, determining \nwhether the pain occurs in the pelvis or at the vaginal opening will help guide additional \ninvestigations and treatments. Involving intimate partners in counselling about dyspareunia with \nthe consent of both parties can also improve the patient-centeredness of care.[30] \nDyspareunia is a primary symptom of endometriosis, yet has been relegated to a secondary or \ntertiary outcome in clinical trials research.[28,29] Other studies have established that \nendometriosis-associated sexual pain negatively affects physical and psychosocial well-being, a \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n12 \n \nfinding that the present work reinforced. This study also provided a comprehensive insight into \nthe experience of dyspareunia in endometriosis, yielding methodological considerations for how \nthis symptom should be measured as well as clinical implications. We hope that by providing a \nrich description of endometriosis-associated sexual pain, this work will be hypothesis-generating \nand will contribute to rigorous investigation of dyspareunia in endometriosis. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint \n\n13 \n \nREFERENCES \n1  Eskenazi B, Warner ML. Epidemiology of endometriosis. Obstet Gynecol Clin North Am \n1997;24:235–58. doi:10.1016/S0889-8545(05)70302-8 \n2  Fauconnier A, Chapron C, Dubuisson J-B, et al. Relation between pain symptoms and the \nanatomic location of deep infiltrating endometriosis. Fertil Steril 2002;78:719–26. \ndoi:10.1016/S0015-0282(02)03331-9 \n3  Ferrero S, Esposito F, Abbamonte LH, et al. Quality of sex life in women with endometriosis \nand deep dyspareunia. Fertil Steril 2005;83:573–9. doi:10.1016/j.fertnstert.2004.07.973 \n4  Shum LK, Bedaiwy MA, Allaire C, et al. Deep Dyspareunia and Sexual Quality of Life in \nWomen With Endometriosis. Sex Med 2018;6:224–33. doi:10.1016/j.esxm.2018.04.006 \n5  Denny E, Mann CH. Endometriosis-associated dyspareunia: the impact on women’s lives. \nBMJ Sex Reprod Health 2007;33:189–93. doi:10.1783/147118907781004831 \n6  Jones G, Jenkinson C, Kennedy S. The impact of endometriosis upon quality of life: a \nqualitative analysis. 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Best Pract Res Clin Obstet Gynaecol \n2018;50:11–7. doi:10.1016/j.bpobgyn.2018.01.009 \n \n \n \n \n \nAll rights reserved. No reuse allowed without permission. \nwas not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. \nThe copyright holder for this preprint (whichthis version posted September 12, 2019. ; https://doi.org/10.1101/19005793doi: medRxiv preprint","source_license":"CC0","license_restricted":false}